Bulimia: An Integrated Map of Nine Key Elements

Sparked by a recent meta-analysis of research on personality factors and eating disorders in Clinical Psychology Review, this post maps out nine key components associated with Bulimia Nervosa organized by the unified theory and uses a clinical example to help illustrate the issues.

Bulimia nervosa is a pattern of disordered eating marked by periods of binging followed by restricting, either through purging or other compensatory means designed to prevent weight gain. The restricting behavior is adopted because the individual is preoccupied with concerns of body shape and weight. Research suggests that approximately 2-3 percent of women in the US will experience bulimia in their lifetime, and many more will experience “subclinical” symptoms, including periods of binge eating and having deep concerns about being thin. Although the condition is less common among men, it certainly does occur, perhaps in as many as 0.5 percent of males.

Although there is much information on the web about bulimia, I rarely see it explained at the level of psychological depth necessary to understand all the various elements that go into it. Instead, it usually is just described as a list of symptoms that are fairly obvious, (i.e., there is binging, restricting and concerns about weight), along with a list of related elements, such as depression or low self-esteem and the damage the repeated binge/purge cycle can do to one's body. All of this is then followed by the point that the condition is treatable.

My goal in this rather lengthy blog post is to give folks a deeper understanding of the development of bulimia using my integrated holistic model of psychology as a backdrop to map out the key components. It is worth noting that I got started thinking about integrative models in my master’s program and the first paper I ever wrote on integrative psychotherapy was called a “Cognitive-Interpersonal Model of Bulimia.”

I am going to divide up the components into what I will call “generic components,” which are basic background elements that go into the condition, and then I will discuss the "personality" components, which are the individual difference elements that make particular individuals vulnerable to developing bulimia. The generic elements include the following: 1) Genetics; 2) Habit loops and habit formation; 3) Yoyo dieting and varying self-states; 4) Attraction, relational value and social influence; and 5) The cultural value of thinness.

The personality components include the following: 1) A neurotic and emotionally labile experiential system; 2) An insecure and “other oriented” relationship system; 3) A perfectionistic, critical introject that idealizes thinness; and 4) An emotionally focused and avoidant style of coping with distress. In all, it is a total of nine different elements. That is a lot, which is in part why I broke them down into these two categories. I am going to define the first five generic elements. Then I will describe a case of a college student with bulimia, after that, we can see how the crucial four personality components can be understood.

The Generic Components

1. Genetics. As is probably familiar, you inherit 50 percent of your genetic material from your mother and 50 percent from your father. Genes frame or predispose aspects of development, and there are many propensities towards talents, behavioral patterns, and emotional response tendencies that are quite strongly influenced by genetics. I bite my nails, as does one of my brothers. A second brother started but then was given sufficient reward to stop. Not surprisingly, my father and his father bit their nails.

Bottom line: Genes are not destiny, but they do predispose folks toward certain behavioral repertoires and have been found to be clearly connected to the development of eating disorders. Genes likely play a role via predisposing individuals to the tendencies discussed in the section on individual differences. In particular, they likely play a major role in predisposition for neuroticism and for being other oriented/agreeable.

2. Habit Formation and loops. Patterns of disordered eating can be looked at as maladaptive habits and thus they form as habit loops. A habit loop involves a stimulus which triggers a procedural response which is linked to a consequence. For many reasons, the process of hunger in the context of stress and distress triggers a binge, which offers temporary relief or distraction from negative feelings. But it is secondarily followed by guilt, which triggers some form of “purge,” which reduces the fear of weight gain temporarily. If these steps are repeated, they can easily become a self-reinforcing loop that is ingrained in the habit system.

3. Yoyo dieting and varying self-states. Anyone who has tried to engage in a restrictive diet can see that the first five minutes are a lot easier than the first five days, which are easier than the first five weeks. Why? Because your sense of self varies with mood and motivation. It is a lot easier to promise that you will diet after you just ate than it is to not eat when you are hungry or feeling stressed. Thus, people of all stripes struggle to maintain consistent eating patterns, especially if they start off being too restrictive in their dietary goals, as many individuals with bulimia tend to do.

4. Relational value, social influence, and attraction. A basic human motivation is to be known and valued by important others. We want others to admire, desire, and respect us. It should be no surprise that being physically attractive is an aspect of social influence. More attractive people have (some) more opportunities for being valued and influential (although the relationship between influence and attractiveness is complicated and can be overstated—folks with bulimia often idealize how important attractiveness/thinness is for happiness). And, although both men’s and women’s appearances matter, some evidence suggests it may be a more important social influence factor for women.

5. The thin ideal. What makes someone hot? Check out Hollywood or the Sport Illustrated Swimsuit edition. Overwhelmingly, as a group, they have thin, fit bodies. Most cultures value an hourglass shape in women and a V shape in men, but the value of attractiveness is particularly prevalent in our culture and it is expressed over and over via various media. In modern Western cultures, thinness in women is especially valued relative to other times and places. Moreover, we live in a time when we are both inundated with media messages along these lines, and we simultaneously have abundance of access to excellent tasting foods. And it is as easy as ever to live a sedentary lifestyle, for example, sitting and staring at a screen all day. Thus, we see rising levels of obesity in a culture that idealizes thinness, which is a clear recipe for psychological conflict and distress.

With these generic background elements in place, let me introduce Christina,* a 19-year-old Caucasian college student who came to see me because she had been struggling with bulimia for the past year. She is attractive and well-dressed and polite and rapport is easily established. She appears somewhat overweight and has a desire to lose 30 pounds. She currently binges and purges approximately four times a week, although it can be up to 10 times a week during her worst periods.

She has experienced periods of depression and anxiety starting when she was 14. She was always a bit self-conscious and was particularly concerned about her weight and appearance since she was an adolescent. She played goalie on her high school soccer team, which she liked and kept her active. She reported that she was “somewhat” overweight in high school, but when she came to college a year ago she was not involved in any sports and reported she gained about 15 pounds since coming to college.

She started purging a year ago after she read about bulimia in a magazine. Although a part of her knew it was “wrong,” she tried it and found she could make herself purge easier than she thought and then it quickly became a pattern. She had been doing it secretly, but was discovered a month ago by her roommate, who was supportive, but encouraged her to get help. That was the impetus to come in to the clinic. She has wanted to tell her mother, but has been afraid about burdening her, as she knows it will upset her. She is maintaining good grades, but is stressed all the time, is very disappointed and frustrated with herself, and has regular periods in which she feels deeply depressed, such that she has trouble getting out of bed (although she always does). These down periods typically last a couple of days at a time, but sometimes go on for a week. She has had passive thoughts of dying (i.e., sometimes she wishes she were dead), but has not been actively suicidal.

Here is her story in interview form (it is accelerated to make the key points):

Me: So it has been pretty brutal for you over this past year or so.

Christine: Yes, (tearful), I have been super stressed and definitely had a lot of down periods.

Me: And you are pretty upset about your eating?

Client: Yes. It is pretty out of control at times. And being found out by my roommate was the worst. I have to do something.

Me: Now that I have a sense of the frequency of your binging and purging and low moods, I’d want to get a clearer sense of your development. Can you share where you grew up and how was that?

Client: Well, I grew up in Northern Virginia, just outside of DC. I had a happy childhood. My family was super close. My mom, especially, was always there for me.

Me: It sounds like your mood started to take a turn for the negative in adolescence. Tell me about that.

Client: It showed up first in middle school, in the 8th grade. Then again in high school. In middle school, I got into a huge fight with Amber, who was my best friend. It caused me to lose my group of friends, because we were all a group and most sided with her. I was super upset and lonely for maybe six months.

Me: Did you talk to folks about that?

Client: My mom, some. She was super supportive. But mostly I just kept to myself and tried to do my best not to show that I was upset.

Me: And then something happened in high school?

Client: My younger sister was in a car accident when I was in the 10th grade and was in a coma for a few weeks and then needed lots of rehabilitation. It was super stressful for all of us. About three months after that I started to dip into another low mood.

Me: Did you talk to anyone about that?

Client: Actually, no, I could not. I did not want to be a burden. I mean, my parents were dealing with my sister. I needed to be strong. I would let them know I was sad about my sister and do whatever I could to help. But I did not tell them I was feeling so low. I really felt bad and stupid about this, because here my sister is dealing with this huge nightmare thing, and things were really going fine for me and I was the one who was depressed. I don’t know why I was feeling bad. I had no reason to feel bad, except for what my sister was going through.

Me: It sounds like a part of you just wants to be happy and strong no matter what, but that there is another part, you’re feeling part, that is often stressed and down. And is it the case that those parts are in conflict in you?

Client: Totally. That is exactly it. I am always getting stressed out, which sucks because I don’t think I have any good reason to be stressed out, and so I feel like I am weak and I don’t know what is wrong with me.

Me: And how was your transition to college?

Client: Some good, some bad. I met a good group of friends, and now have lots of people who I can talk with and hang out. School was definitely harder than in high school, but I have been doing ok. But it has been super stressful the whole time. And I have been super stressed about my weight. I know I should go to the gym, and I have some times, but I hate it. I feel weak and fat and silly there. There are all these beautiful, fit people around. And I am now so much more likely to eat when I am stressed.

Me: So a lot of the binges happen when you are stressed?

Client: Yes. And it is almost like a ritual now. I will feel it coming on. Then something will happen that will trigger it. This past week I got a C on my chem lab because I forgot to fill in two questions. I was totally expecting an A. That freaked me out and I was super upset. I absolutely need an A in chem. And I had not binged and purged in two days. So, I just saw the C, pretended it did not bother me, and then just went back to my dorm and stuffed myself.

Me: And then you purged? How do you feel after that?

Client: Tired. And guilty. It is so stupid. I know I should not do that. But I can’t help myself. And I just cannot gain any more weight. So, I just need to stop binging.

Me: So you sort of punish yourself or are critical of yourself afterwards? Indeed, it seems like you carry a very critical voice around inside of you, yes?

Client: I always feel guilty afterwards. And yes, I want to be good and caring and get things right.

Me: And you can get kind of critical and controlling in trying to force yourself to be sort of perfect in this way?

Client: I definitely have a bit of perfectionism in me. Like screwing up the chem lab—I am so pissed at myself for that.

Me: It sounds, though, in relationships with others, you are very understanding and compassionate and giving?

Client: I am definitely a caring person. That is a good thing to be, and it is one of the only things that I like about myself.

Me: So you are much harder on judging yourself than others?

Client: (Pauses). Definitely, now that you mention it. I am definitely super critical of myself, but I don’t feel the same way about others. It is much easier to be kind to other people.

Me: It sounds like you judge yourself for any performance screw-ups and for your negative feelings. It is fair to say that you are critical of yourself for your negative feelings and you try to “get them off the stage” of your awareness. Is that right?

Client: Yes, definitely.

Me: Do you sort of zone out when you binge eat?

Client: Yes.

Me: Do you think that one of the reasons you binge eat is to escape from your negative feelings. That it sort of is a short term solution to getting those stressful feelings off the stage?

Client. Definitely.

***

With this clinical presentation offered, let’s now spell out some of the key personality components that are associated with bulimia.

1. A neurotic temperament and emotionally labile experiential system. Personality traits refer to broad dispositional differences in ways individuals tend to feel, think, and act. They emerge in childhood and then solidify in adulthood. A neurotic temperament or “trait neuroticism” refers to the “set point” of one’s negative emotion system. This means that one who is high on neuroticism will have more frequent and intense negative emotional reactions to stressors, will take longer to calm down, and will have more negative or pessimistic thoughts about their environment.

There are some elements of neuroticism that are relevant for bulimia. One is “emotional lability” which refers to ups and downs of the emotional system. Another is negative urgency, which refers to the tendency of an individual to impulsively act out when feeling stressed. Individuals with bulimia are high on neuroticism, and on the subdomains of emotional lability and negative urgency. (For more detail, see Farstad, McGeown, & von Ranson, 2016, cited at the end of the blog).

2. An insecure and “other-oriented” relationship system. The unified approach uses the influence matrix to map the human relationship system. Folks with bulimia usually have significant insecurities in at least one of the major relationships domains (family of origin, peers/friends, romantic partners, group affiliations). Even if they report good relationships (which is not uncommon), it is important to keep in mind, security is found in being valued and known. Many bulimic individuals feel valued in some ways, but often they do not feel truly “known” because they have deep seated insecurities about their true selves and they often try to hide problematic behaviors that they see as shameful. Thus many often feel like imposters. In terms of their interpersonal style, many individuals with bulimia focus on the needs of others, sacrifice their own needs, and turn any anger they feel back on themselves to keep their public presentation to be caring, loyal, and easy going.

3. A perfectionistic, critical self-concept that idealizes thinness. According to the unified approach, we should divide human consciousness up into the experiential self, the private self and the public self. The private self is the internal narrator that is making sense of your experiences and the world around you, houses your explicit self-concept, and regulates your behavior in relationship to the social field (i.e., it plays a central role in managing your public self). Feeling “self-conscious” describes the process by which the internal narrator becomes particularly active in trying to filter out problematic displays, utterances, and performances.

The inner narrator becomes critical when one’s performance is not living up to expectations. The function here is to try to (a) motivate the individual to work harder and (b) to avoid doing “stupid things” that others will judge and punish. Individuals with bulimia often develop a critical narrator that is trying to ensure that they present themselves publically as “the good girl,” meaning they want to always be kind, giving, strong, achievement oriented and sensitive to the needs of others. This “private introject” can be a harsh, perfectionistic critic and is often particularly critical of issues pertaining to negative feelings; weight, eating, and dieting; and weak or ineffective performances.

4) An emotionally focused and avoidant style of coping with distress. In the unified approach, the defensive system refers to how individuals try to maintain psychic equilibrium. One key area is in how the private self relates to the experiential system. For example, how do people react to emerging feelings, impulses or wishes? Can they effectively recognize what they are feeling, what information is conveyed by these feelings, and proceed to adaptively regulate their behavior while being informed by but not being controlled by their feelings? Doing so is operating within the emotional sweet spot. Or do they treat negative feelings as problem, do what they can to get feelings out of the way and then sometimes are overwhelmed by a crash of emotion, after some stressor releases all the pent up feelings?

Operating outside the emotional sweetspot is a recipe for trouble. And it occurs often for folks who see negative feelings as the problem to be solved (emotion focused coping), rather than as information about a problem in the world that needs attention (solution focused coping). Trying to experientially control and avoid feelings sets the stage for many different kinds of coping strategies for distraction, and binge eating is one such strategy that many individuals with bulimia develop into as a habit for coping with unwanted negative feelings.

To wrap this lengthy blog post up, let’s place Christine’s presentation in narrative form. She grew up in a caring and close household, which certainly is a positive. However, it was also the case that negative feelings were not dealt with in the healthiest of ways and she learned early on to try to suppress or compartmentalize her negative feelings. This was fine for her early childhood, as she was generally happy and well-loved. But when she got to middle school, she found it hard to cope with the rough and tumble world of teenage girls. She was always nice, had trouble asserting herself and could be dominated. The rift with her best friend created many negative feelings but she did not learn how to work them through. She could cry to her mom, but that did not solve much.

Then with the accident involving her sister, she had to be strong and helpful and giving for her family. This really created in internal introject that blamed herself if she felt anything that she should not. This was a problem because Christine was somewhat high on trait neuroticism, meaning that she had a sensitive negative emotional system that was difficult to sooth and oriented her toward urgent impulses that would address the negative feelings. There was not really either an interpersonal or intrapsychic relational space where these feelings could be held. Instead, she generally tried to hide them from others and spent much intrapsychic energy trying to punish herself out of her feelings.

The consequence was an intrapsychic struggle that resulted in much inner distress. Desperately wanting to be someone who was accepted and seen as desirable and admirable, she internalized the thin ideal sometime in late adolescence and became convinced that if she was thin and beautiful she would find happiness. She promised herself she would get thin in college, but the reverse was happening. And she hated that. She tried to force herself to diet, but would inevitably eat, and then overeat when she was stressed. It was one way she could escape, at least temporarily from all the demands and the negative feelings. But, of course, as soon as the binge was over, her critical self-conscious system returned full force.

Then she got the idea to purge. Again, this provided short term relief. Now she could binge and then be relieved of the calories and that shame. But the purging added a whole other layer of shame. And forced her to hide more than ever. This, of course, made her feel even more like an imposter and have an even bigger split between her private feelings, her critical introject and the public image she was trying to present. All of this inner disharmony was now resulting in her system starting to more fully shutdown and a major depressive episode was emerging.

The goal of this blog post is to help readers understand the pieces that go into bulimia nervosa and how these pieces interact across development in a way that gives rise to this troubling pattern. Of course, many will wonder about treatment. That is another topic. But, consistent with this analysis, effective treatments will likely focus on breaking the habit loop using basic learning principles to alter the reinforcement patterns that drive binging and purging, focusing on idealized beliefs about thinness, focusing on increasing self-compassion, focusing on attachment insecurities and a more balanced self-other interpersonal style, and increasing psychological mindedness and fostering more capacity to operate in the emotional sweet spot.

*As is always the case, unless explicitly stated otherwise, the clients I present are realistic models, but do not actually represent any specific individual.